Introduction

Laparoscopic cholecystectomy (LC), one of the most commonly performed surgical procedures worldwide is accepted as the gold standard in the treatment of symptomatic gallstones [11. Sahu SK, Agrawal A, Sachan PK (2013) Intraoperative Difficulties in Laparoscopic Cholecystectomy. Jurnalul de Chirurgie (Iaşi) 2: 149-155.]. Preoperative assessment of complexity factors is needed for frequent procedures such as (LC) in order to avoid complications and delays and to guarantee an efficient course of surgery [22. Sodergren M, Orihuela-Espina F, Clark J, Teare J, Yang G, et al. (2010) Evaluation of orientation strategies in laparoscopic cholecystectomy. Annals of Surgery 252: 1027-36.]. In case of laparoscopic cholecystectomy, preoperative complexity estimation helps surgeons deciding whether to proceed with a minimally invasive approach, perform an open procedure or make a referral to a more experienced surgeon. It may also be useful for explaining the various risks of laparoscopic and open procedures [11. Sahu SK, Agrawal A, Sachan PK (2013) Intraoperative Difficulties in Laparoscopic Cholecystectomy. Jurnalul de Chirurgie (Iaşi) 2: 149-155.]. Although laparoscopic cholecystectomy has generally a low incidence of morbidity and mortality and of conversion rate to open surgery, its outcome is particularly affected by the presence and severity of inflammation, advancing patient’s age, male sex and greater body mass index [33. Kanakala V, Borowski DW, Pellen MG, Dronamraju SS, Woodcock SA, et al. (2011) Risk factors in laparoscopic cholecystectomy: a multivariate analysis. Int J Surg. 9: 318-23.]. Previous upper abdominal surgery is associated with a higher rate of adhesions, an increased risk of operative complications, a greater conversion rate, a prolonged operating time and longer stay [33. Kanakala V, Borowski DW, Pellen MG, Dronamraju SS, Woodcock SA, et al. (2011) Risk factors in laparoscopic cholecystectomy: a multivariate analysis. Int J Surg. 9: 318-23.,44. Bouasker I, El Ouaer MA, Smaali I, Khalfallah M, Ben Achour J, et al. (2010) Laparascopic cholecystectomy on a previously operated abdomen. Tunis Med 88: 88-91.]. Laparoscopic cholecystectomy after endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (ES) for combined choledochocystolithiasis is more difficult with prolonged procedure than in uncomplicated gallstone disease with a longer post-operative hospital stay [55. Reinders JS, Gouma DJ, Heisterkamp J, Tromp E, van Ramshorst B, et al. (2013) Laparoscopic cholecystectomy is more difficult after a previous endoscopic retrograde cholangiography. HPB (Oxford) 15: 230-4.].

Objectives

The aim of this study was to trace the outcome of laparoscopic cholecystectomy in our patients with difficult situation according to the recently published scoring system [66. Gupta N, Ranjan G, Arora MP, Goswami B, Chaudhary P, et al. (2013) Validation of a scoring system to predict difficult laparoscopic cholecystectomy. Int J Surg 11: 1002-6.].

Patients and Methods

A total of 204 patients with difficult situation cholecystitis were enrolled to this study from April 2007 to January 2014 at Port-Fouad general hospital and Suez-Canal University hospital. Surgical interference for patients with acute cholecystitis was done within 72 hours from the onset of symptoms of the acute inflammation. Written consent was obtained from all patients or first degree relatives before the management procedure and the local ethics committee approved the study.

Preoperative workup

The triad of clinical examination, laboratory data and ultrasound study was preformed for all patients. Ultrasonography findings for diagnosis of acute cholecystitis were confirmed when sonographic Murphy sign with tenderness on ultrasound probing was elicited. Thickened gallbladder wall >4 mm and enlarged gallbladder with long axis diameter >8 cm, short axis diameter >4 cm. Sonolucent layer in the gallbladder wall, striated intramural lucencies, and pericholecystic fluid collection [77. Yamashita Y, Takada T, Strasberg SM, Pitt HA, Gouma DJ, et al. TG13 surgical management of acute cholecystitis. J Hepatobiliary Pancreat Sci 20: 89-96.].

Grading of acute cholecystitis

Grade I; mild acute cholecystitis is defined as acute cholecystitis in a healthy patient with only mild inflammatory changes in the gallbladder. Grade II; moderate acute cholecystitis is diagnosed when palpable tender mass in the right upper abdominal quadrant with marked local inflammation in US together with WBC count >18 000/mm3. Grade III; severe acute cholecystitis is accompanied by organ dysfunctions [88. Saber A, Hokkam EN (2014) Operative outcome and patient satisfaction in early and delayed laparoscopic cholecystectomy for acute cholecystitis. Minimally Invasive Surgery [In press].].

Difficulty scoring

We relied on the recently advocated scoring system by Coupta and his colleagues [66. Gupta N, Ranjan G, Arora MP, Goswami B, Chaudhary P, et al. (2013) Validation of a scoring system to predict difficult laparoscopic cholecystectomy. Int J Surg 11: 1002-6.] which depends on three main items; patient’s history, clinical data and imaging study. Score of (0–5) indicates an easy approach while score of (6–10) indicates difficult approach and very difficult approach is observed with score of (11–15).

Assessment of adhesion extent

Intra-abdominal adhesion was graded as previously stated in our simplified scoring [99. Saber A (2010) Effect of honey versus intergel in intraperitoneal adhesion prevention and colonic anastomotic healing: A randomized controlled study in rats. I J S 8: 121-127. ]. This scoring system advocated evaluation of the extent of adhesion as localized, moderate and extensive.

Bleeding during surgery is usually graded as minimal when is loss of less than 750 ml, moderate when loss ranges750-1500 ml or severe when loss reaches 1500-2000 ml. Moderate bleeding is defined as bleeding leading to tachycardia of greater than 100/min without drop in blood pressure. Severe bleeding is defined as bleeding leading to tachycardia of greater than 100/min with a greater than 10 mm Hg drop in blood pressure [1010. Pacagnella RC1, Souza JP, Durocher J, Perel P, Blum J, et al. (2013) A systematic review of the relationship between blood loss and clinical signs. PLoS One 8: e57594. ].

Intra-operative blood loss estimation

Estimation of intra-operative blood loss is governed by visual method [1111. Sukprasert M, Choktanasiri W, Ayudhya NI, Promsonthi P, O-Prasertsawat P (2006) Increase accuracy of visual estimation of blood loss from education programme. J Med Assoc Thai. 89:S54-S9.] and the clinical assessment with collaboration with the anesthetist [1010. Pacagnella RC1, Souza JP, Durocher J, Perel P, Blum J, et al. (2013) A systematic review of the relationship between blood loss and clinical signs. PLoS One 8: e57594. ]. Regarding visual estimation of blood loss; a standard absorptive gauze measuring 30 cm X 30 cm was used. When it was soaked by 50 % the means that it contains about 25 ml of blood and if totally soaked; 100% this means that it contains 75 ml of blood [1111. Sukprasert M, Choktanasiri W, Ayudhya NI, Promsonthi P, O-Prasertsawat P (2006) Increase accuracy of visual estimation of blood loss from education programme. J Med Assoc Thai. 89:S54-S9.].

Operative technique

Laparoscopic cholecystectomy was performed using the standard 4-trochar technique. Gallbladder contents were aspirated in cases with gallbladder distension. Meticulous dissection was paid to identify the structures in Calots triangle and attempts of retrograde dissection of the gallbladder starting at the fundus were done in case of severe inflammation and anatomical difficulty of the pericystic space. We used plastic bags for gallbladder removal from the abdomen for prevention of wound infection and falling of stones.

End Points

The primary end point of the study was operative outcome and the second end point was morbidity related to surgery.

Results

The demographic data of our patients are studied according to age, sex and their special habits as shown in table 1.

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   Table 1:

   Showing demographic data of our patients.
   
   

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   Table 1: Showing demographic data of our patients.
   Item		Male	Female
   Age	≤ 50 years	24	80
   	≥ 50 years	62	36
   BMI	≤ 25 ; 22-24.9	40	38
   	≤ 30; 25-29.9	28	48
   	≥ 30; 30-34.9	20	30
   Special habits	Smoking	30	10
   	Drugs	12	--
   	Sports	16	16
   	Nothing	30	90

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   Table 2:

   Showing preoperative complexity factors in our series.
   
   

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   Table 2: Showing preoperative complexity factors in our series.
   Item	Status	Sex		Total
   		F	M
   Abdominal wall scars [N = 38]	Infra- umbilical scars	15	-	15
   	supra-umbilical scars	7	10	17
   	Burn cicatrization	2	4	6
   Intra-abdominal adhesions [ N = 28]	Moderate	4	8	12
   	Extensive	6	10	16
   Gall bladder pathology [ N = 118]	acute cholecystitis	60	20	80
   	Fibrotic gall bladder	6	12	18
   	Stone load	6	14	20
   ERCP [ N = 20]		10	10	20
   Total		116	88	204

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   Table 3:

   Showing intra-operative complications.
   
   

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   Table 3: showing intra-operative complications.
   Complication	AC		FG		Adhesion		Hge		Total
   	M	F	M	F	M	F	M	F	M	F
   Bleeding	5	5	3	1	1	1	-	-	9	7
   Conversion	4	4	2	-	1	-	2	2	9	6
   Leak	2	2	1	2	1	1	-	-	4	5
   Infection	6	4	1	1	1	1	2	2	10	8
   Total	17	15	7	4	4	3	4	4	32	26
   									58

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The range of operative time was between 45-200 minutes with a mean value of 65.7± 26.08 minutes with the minimum value was 45 and the maximum was 200 minutes respectively. The abdominal wall status was studied according to the presence of surgical, nonsurgical scars and deformity with total number of 38 patients. Infra- umbilical scars were present in 15 patients while supra-umbilical scars were present in 17 patients. Burn cicatrization of abdominal wall was seen in 6 patients and thoracic cage and spine deformity were observed in 4 patients. Intra-abdominal adhesion was graded as previously stated in our simplified scoring [9] and accordingly, moderate and extensive adhesions were detected in 12 and 16 patients respectively.

Grades and severity of acute cholecystitis were traced in our patients according to the clinical finding, laboratory data and imaging studies. Only grade I and grade II were included. There were 80 patients with acute cholecystitis, 18 patients dense fibrotic gall bladder and 20 patients had their gall bladder loaded with stones. We had 20 patients operated upon after ERCP.

The total number of male patients was 88, 62/88 patients (70.4%) were above 50 years and 48/88 patients were obese and overweighed [28/88(31.8%) and 20/88(22.7%) respectively]. The majority of female patients 80/116 were under 50 years (68.9%) while and 48/116 (41.3%) patients were obese and 30/116 were overweighed (25.8%).

There was no operative mortality and the 30- day death was 6 (2.54%) and the overall complication rate was 28.43% (58/ 204 patients). The operative outcome was represented as operative bleeding and conversion to open surgery while the postoperative outcome was biliary leakage and port site infection. The overall operative bleeding was observed in 16 patients (7.84%), 10 with acute cholecystitis, 4 with fibrotic gall bladder and 2 patients with extensive peritoneal adhesion. Most of patients with operative bleeding were male patients 9/88 (10.2%) 6/9 patients presented with acute cholecystitis and above 50 years of age with higher body mass indices. The total score for each patient of these 9 patients was between 6-10 points indicating difficult surgical approach according to Gupta et al scoring system [66. Gupta N, Ranjan G, Arora MP, Goswami B, Chaudhary P, et al. (2013) Validation of a scoring system to predict difficult laparoscopic cholecystectomy. Int J Surg 11: 1002-6.]. The incidence of operative bleeding in females in our group was 7/ 116 (6.3%), most of them were presented with acute cholecystitis and fibrotic gall bladder and having score for each patient between 6-10 points. Our overall conversion rate was 15/ 204 patients (7.35%) and the most common cause of conversion was acutely inflamed gall bladder with the resultant difficult dissection at Calot triangle (8/15 patients). Bleeding with failed clipping due to obscure anatomy was a cause to convert into open in 4/15 patients while adhesion and fibrotic gall bladder were responsible for conversion in 3/15 patients.

Most of patients with conversion to open cholecystectomy were male patients 9/88 (10.2%) 4/9 patients presented with acute cholecystitis and above 50 years of age with higher body mass indices. The total score for each patient of these 9 males was between 6-10 points indicating difficult surgical approach according to Gupta et al scoring system [66. Gupta N, Ranjan G, Arora MP, Goswami B, Chaudhary P, et al. (2013) Validation of a scoring system to predict difficult laparoscopic cholecystectomy. Int J Surg 11: 1002-6.]. The incidence of conversion to open cholecystectomy in females in our group was 6/ 116 (5.17%), most of them were presented with acute cholecystitis and fibrotic gall bladder and having score for each patient between 6-10 points.

Postoperative biliary leakage was observed in 9 patients (4.4%) 4 males (4. 5%) and 5 females (4.3%) and all having score between 6-10 points. The incidence of wound infection, whether port site or laparotomy was 18/204 (8.82%), 10 of them were males (11.3 % of total male patients) and 8 females (6.9% of total female patients).

Discussion

Difficult laparoscopic cholecystectomy is defined in those procedures which exceed 90 minutes in duration and or are converted to open procedure and significant factors which increase the operating time are previous abdominal surgery, multiple large calculi, very thick walled gallbladder, anomalous vessels, large and distended gallbladder [11. Sahu SK, Agrawal A, Sachan PK (2013) Intraoperative Difficulties in Laparoscopic Cholecystectomy. Jurnalul de Chirurgie (Iaşi) 2: 149-155.]. The mean operative time in our study came in agreement with those in others of same interest. The mean operative time ranges between 60-110 minutes with maximum values of 250-280 in those studies [11. Sahu SK, Agrawal A, Sachan PK (2013) Intraoperative Difficulties in Laparoscopic Cholecystectomy. Jurnalul de Chirurgie (Iaşi) 2: 149-155.,33. Kanakala V, Borowski DW, Pellen MG, Dronamraju SS, Woodcock SA, et al. (2011) Risk factors in laparoscopic cholecystectomy: a multivariate analysis. Int J Surg. 9: 318-23.,44. Bouasker I, El Ouaer MA, Smaali I, Khalfallah M, Ben Achour J, et al. (2010) Laparascopic cholecystectomy on a previously operated abdomen. Tunis Med 88: 88-91.,88. Saber A, Hokkam EN (2014) Operative outcome and patient satisfaction in early and delayed laparoscopic cholecystectomy for acute cholecystitis. Minimally Invasive Surgery [In press].].

Difficult laparoscopic cholecystectomy is associated with serious operative and postoperative complications and a high conversion rate [1212. Hussain A (2011) Difficult laparoscopic cholecystectomy: current evidence and strategies of management. Surg Laparosc Endosc Percutan Tech 21: 211-7.]. Vivek and colleagues traced difficulty as in creating pneumoperitoneum, accessing peritoneal cavity, releasing adhesions, identifying anatomy and extracting the gall bladder [1313. Vivek MK, Augustine AJ, Rao R (2014) A comprehensive predictive scoring method for difficult laparoscopic cholecystectomy. J Min Access Surg 10: 62-7. ]. Previous attacks of acute cholecystitis, GB wall thickness, inability to delineate the anatomy and previous abdominal surgery are some of the factors that have been identified as potential risk factors for the conversion [1414. Vyas HG, Bhandari V, Saurabh, Tiwari P, Singh M (2013) Pre-operative predictors of difficult laparoscopic cholecystectomy; comparisons of two scoring systems. A single center prospective study. J Evol Med Dent Scie 2: 7855-7862.]. Accordingly in concordance with these studies [1212. Hussain A (2011) Difficult laparoscopic cholecystectomy: current evidence and strategies of management. Surg Laparosc Endosc Percutan Tech 21: 211-7.-1414. Vyas HG, Bhandari V, Saurabh, Tiwari P, Singh M (2013) Pre-operative predictors of difficult laparoscopic cholecystectomy; comparisons of two scoring systems. A single center prospective study. J Evol Med Dent Scie 2: 7855-7862.] our data showed that burn cicatrization and supra-umbilical surgical scars led to difficult creation of pneumoperitoneum and difficult accessing peritoneal cavity.

Peritoneal adhesions may be mild, moderate or extensive according to extent as reported by Saber in his experimental work [99. Saber A (2010) Effect of honey versus intergel in intraperitoneal adhesion prevention and colonic anastomotic healing: A randomized controlled study in rats. I J S 8: 121-127. ]. In our study, extensive peritoneal adhesions were responsible for 8.62% of the overall complication rate especially operative bleeding and conversion to open surgery. Many studies of same interest reported that previous upper abdominal surgery is associated with a higher rate of adhesions, an increased risk of operative complications, a greater conversion rate, a prolonged operating time and longer stay [44. Bouasker I, El Ouaer MA, Smaali I, Khalfallah M, Ben Achour J, et al. (2010) Laparascopic cholecystectomy on a previously operated abdomen. Tunis Med 88: 88-91.,1515. Sultan AM, El Nakeeb A, Elshehawy T, Elhemmaly M, Elhanafy E, et al. (2013) Risk Factors for Conversion during Laparoscopic Cholecystectomy: Retrospective Analysis of Ten Years' Experience at a Single Tertiary Referral Centre. Dig Surg 30: 51-55.-1717. Karayiannakis AJ, Polychronidis A, Perente S, Botaitis S, imopoulos C (2004) Laparoscopic cholecystectomy in patients with previous upper or lower abdominal surgery. Surg Endosc 18: 97-101.].

Incidence of operative bleeding in many series was up to 10% with an average figure of 2% [1818. Kaushik R (2010) Bleeding complications in laparoscopic cholecystectomy: Incidence, mechanisms, prevention and management. J Min Access Surg 6: 59-65. ]. The most important patient-related risk factors of operative bleeding are acute cholecystitis, liver cirrhosis, previous abdominal surgery, peritoneal adhesion and anatomical abnormalities [1818. Kaushik R (2010) Bleeding complications in laparoscopic cholecystectomy: Incidence, mechanisms, prevention and management. J Min Access Surg 6: 59-65. -2020. Honchar MH, Hlushchuk OM (2012) Intraoperative complications during performance of laparoscopic cholecystectomy. Klin Khir 39-41.]. Our data came in agreement with these results as we observed that operative bleeding was 7.84% in patients with acute cholecystitis, fibrotic gall bladder and extensive peritoneal adhesion. The achievement of the critical view of safety (CVS) requires complete dissection of the fat and fibrous tissue in the Calot’s triangle which can be performed easily with inflamed or mildly inflamed field [2121. Fujita T (2010) Critical View of Safety for Laparoscopic Removal of Difficult Gall bladder. Am J Surg 211: 690-691.-2323. Sanjay P, Fulke JL, Exon DJ (2010) Critical view of safety' as an alternative to routine intraoperative cholangiography during laparoscopic cholecystectomy for acute biliary pathology. J Gastrointest Surg 14: 1280-4.].

In general, laparoscopic cholecystectomy shows an approximately 5% to 10% conversion rate and difficult cases are associated with a conversion rate of 25%. The major risk factors for conversion in these difficult cases included male sex, obesity, and cholecystitis [1717. Karayiannakis AJ, Polychronidis A, Perente S, Botaitis S, imopoulos C (2004) Laparoscopic cholecystectomy in patients with previous upper or lower abdominal surgery. Surg Endosc 18: 97-101.,2424. Livingston EH, Rege RV (2004) A nationwide study of conversion from laparoscopic to open cholecystectomy. Am J Sur 188: 205-211.,2525. Szabo K, Rothe A and Shamiyeh A (2012) Laparoscopic cholecystectomy – review over 20 years with attention on acute cholecystitis and conversion. European Surgery 44: 28-32.], dense pericholecystic adhesion or unclear anatomy, uncontrolled bleeding and thick fibrosed gall bladder [2626. Ahmed S, Ali AA, Hasan M, Awal A. Problems leading to conversion in laparoscopic cholecystectomy. Mymensingh Med J 22: 53-8.]. Our data showed that conversion was more prevalent patients with acute cholecystitis (8/15 patients), operative uncontrollable bleeding (4/15) and fibrotic gall bladder and dense adhesion (3/15).

The estimation based on patient characteristics such as gender, age and body weight showed that both operative bleeding and the conversion rate were higher in male patients with advanced age and increases body mass indices [1717. Karayiannakis AJ, Polychronidis A, Perente S, Botaitis S, imopoulos C (2004) Laparoscopic cholecystectomy in patients with previous upper or lower abdominal surgery. Surg Endosc 18: 97-101.,2727. Jethwani U, Singh G, Mohil RS, Kandwal V, Razdan S, et al. (2013) Prediction of difficulty and conversion in laparoscopic cholecystectomy. OA Min Inv Surg 1: 1-5.,2828. Giger UF, Michel JM, Opitz I, Th Inderbitzin D, Kocher T, et al. (2006) Swiss Association of Laparoscopic and Thoracoscopic Surgery (SALTS) Study Group. Risk factors for perioperative complications in patients undergoing laparoscopic cholecystectomy: analysis of 22,953 consecutive cases from the Swiss Association of Laparoscopic and Thoracoscopic Surgery database. J Am Coll Surg 203: 723-8.].

Other investigators traced six parameters (male sex, abdominal tenderness, previous upper abdominal operation, sonographically thickened gallbladder wall, age over 60 years, preoperative diagnosis of acute cholecystitis) to have significant effect conversion to open cholecystectomy [66. Gupta N, Ranjan G, Arora MP, Goswami B, Chaudhary P, et al. (2013) Validation of a scoring system to predict difficult laparoscopic cholecystectomy. Int J Surg 11: 1002-6.,2929. Zdichavsky M, Bashin YA, Blumenstock G, Zieker D, Meile T, et al. (2012) Impact of risk factors for prolonged operative time in laparoscopic cholecystectomy. Eur J Gastroenterol Hepatol 24: 1033-8.,3030. Kama NA, Kologlu M, Doganay M, Reis E, Atli M, et al. (2001) A risk score for conversion from laparoscopic to open cholecystectomy. Am J Surg. 181: 520-5.]. The total score for prediction of operative difficulties and conversion to open cholecystectomy was given to every patient on the basis of history, clinical examination and ultrasonographic findings [66. Gupta N, Ranjan G, Arora MP, Goswami B, Chaudhary P, et al. (2013) Validation of a scoring system to predict difficult laparoscopic cholecystectomy. Int J Surg 11: 1002-6.]. The total score for each of our patients with conversion to open surgery or with postoperative biliary leakage was between 6-10 points indicating difficult surgical approach according to Gupta scoring system [66. Gupta N, Ranjan G, Arora MP, Goswami B, Chaudhary P, et al. (2013) Validation of a scoring system to predict difficult laparoscopic cholecystectomy. Int J Surg 11: 1002-6.] and other studies of same interest [1212. Hussain A (2011) Difficult laparoscopic cholecystectomy: current evidence and strategies of management. Surg Laparosc Endosc Percutan Tech 21: 211-7.,3131. Nachnani J, Supe A (2005) Pre-operative prediction of difficult laparoscopic cholecystectomy using clinical and ultrasonographic parameters. Indian J Gastroenterol 24: 16-18.,3232. Abdel Baki NA, Motawei MA, Soliman KE, Farouk AM (2006) Pre-operative prediction of difficult laparoscopic cholecystectomy using clinical and ultrasonographic parameters. JMRI 27:102-107.].

Conclusion

Difficult cases for laparoscopic cholecystectomy should be recognized in the preoperative course and operated by experienced surgeons as these cases carry a higher risk of conversion to open surgery and complications. Preoperative prediction of the risk factors of conversion or difficulty of operation is an important point for operative planning and the high risk patients may be informed accordingly.